Page 142 - JSOM Fall 2018

7. Hypothermia Prevention Analgesia notes:
a. Minimize casualty’s exposure to the elements. Keep a. Casualties may need to be disarmed after being given
protective gear on or with the casualty if feasible. OTFC or ketamine.
b. Replace wet clothing with dry if possible. Get the casu­ b. Document a mental status exam using the AVPU
alty onto an insulated surface as soon as possible. method prior to administering opioids or ketamine.
c. Apply the Ready­Heat Blanket from the Hypothermia c. For all casualties given opioids or ketamine – monitor
Prevention and Management Kit (HPMK) to the ca­ airway, breathing, and circulation closely
sualty’s torso (not directly on the skin) and cover the d. Directions for administering OTFC:
casualty with the Heat­Reflective Shell (HRS). • Recommend taping lozenge­on­a­stick to casualty’s
d. If an HRS is not available, the previously recom­ finger as an added safety measure OR utilizing a
mended combination of the Blizzard Survival Blanket safety pin and rubber band to attach the lozenge (un­
and the Ready Heat blanket may also be used. der tension) to the patient’s uniform or plate carrier.
e. If the items mentioned above are not available, use • Reassess in 15 minutes
dry blankets, poncho liners, sleeping bags, or anything • Add second lozenge, in other cheek, as necessary to
that will retain heat and keep the casualty dry. control severe pain
f. Warm fluids are preferred if IV fluids are required. • Monitor for respiratory depression
8. Penetrating Eye Trauma e. IV Morphine is an alternative to OTFC if IV access has
a. If a penetrating eye injury is noted or suspected: been obtained
• Perform a rapid field test of visual acuity and docu­ • 5mg IV/IO
ment findings. • Reassess in 10 minutes.
• Cover the eye with a rigid eye shield (NOT a pressure • Repeat dose every 10 minutes as necessary to con­
patch.) trol severe pain.
• Ensure that the 400mg moxifloxacin tablet in the • Monitor for respiratory depression.
Combat Wound Medication Pack (CWMP) is taken f. Naloxone (0.4mg IV or IM) should be available when
if possible and that IV/IM antibiotics are given as using opioid analgesics.
outlined below if oral moxifloxacin cannot be taken. g. Both ketamine and OTFC have the potential to worsen
9. Monitoring severe TBI. The combat medic, corpsman, or PJ must
a. Initiate advanced electronic monitoring if indicated consider this fact in his or her analgesic decision, but
and if monitoring equipment is available. if the casualty is able to complain of pain, then the
10. Analgesia TBI is likely not severe enough to preclude the use of
a. Analgesia on the battlefield should generally be achieved ketamine or OTFC.
using one of three options: h. Eye injury does not preclude the use of ketamine. The
• Option 1 risk of additional damage to the eye from using ket­
– Mild to Moderate Pain amine is low and maximizing the casualty’s chance for
– Casualty is still able to fight survival takes precedence if the casualty is in shock or
o TCCC Combat Wound Medication Pack respiratory distress or at significant risk for either.
(CWMP) i. Ketamine may be a useful adjunct to reduce the
*Tylenol – 650mg bilayer caplet, 2 PO every amount of opioids required to provide effective pain
8 hours relief. It is safe to give ketamine to a casualty who has
*Meloxicam – 15mg PO once a day previously received morphine or OTFC. IV Ketamine
• Option 2 should be given over 1 minute.
– Moderate to Severe Pain j. If respirations are noted to be reduced after using opi­
– Casualty IS NOT in shock or respiratory dis­ oids or ketamine, provide ventilatory support with a
tress AND bag­valve­mask or mouth­to­mask ventilations.
– Casualty IS NOT at significant risk of develop­ k. Ondansetron, 4mg Orally Dissolving Tablet (ODT)/
ing either condition IV/IO/IM, every 8 hours as needed for nausea or vom­
o Oral transmucosal fentanyl citrate (OTFC) iting. Each 8­hour dose can be repeated once at 15
800μg minutes if nausea and vomiting are not improved. Do
*Place lozenge between the cheek and the gum not give more than 8mg in any 8­hour interval. Oral
*Do not chew the lozenge ondansetron is NOT an acceptable alternative to the
• Option 3 ODT formulation.
– Moderate to Severe Pain l. Reassess – reassess – reassess!
– Casualty IS in hemorrhagic shock or respiratory 11. Antibiotics: recommended for all open combat wounds
distress OR a. If able to take PO meds:
– Casualty IS at significant risk of developing ei­ – Moxifloxacin (from the CWMP), 400mg PO once
ther condition a day
o Ketamine 50mg IM or IN b. If unable to take PO meds (shock, unconsciousness):
OR – Ertapenem, 1gm IV/IM once a day
o Ketamine 20mg slow IV or IO 12. Inspect and dress known wounds.
*Repeat doses q30min prn for IM or IN 13. Check for additional wounds.
*Repeat doses q20min prn for IV or IO 14. Burns
*End points: Control of pain or develop­ a. Facial burns, especially those that occur in closed spaces,
ment of nystagmus (rhythmic back­and­forth may be associated with inhalation injury. Aggressively
movement of the eyes) monitor airway status and oxygen saturation in such

140 | JSOM Volume 18, Edition 3 / Fall 2018